Questions for general practice

Tudor Hart describes the real stuff of primary medical care as the steady unglamorous slog of anticipatory care, where the exciting things have been events that have not happened.¹ When acute events do occur, as in this case, the electronic responses from Bossano and Trivanovic rightly highlight the difficulties in diagnosing chest pain in the community without access to sophisticated investigations.²

Good consultation skills are always important. Peter Hartl's description of his pain before admission is in itself a sensitive test for acute thoracic aortic dissection.³ His inability to explain why he did not seek help immediately is interesting. In myocardial infarction, patients' delay in calling for help has been described as the weakest link in the chain of survival. The most critical factor is the recognition that the symptoms are cardiac in origin.⁴ Should part of our education for patients at high risk of acute cardiovascular emergencies include how to respond to acute chest pain?

Three respondents said that a previous electrocardiogram would have helped interpret the electrocardiographic appearances on admission. With the increasing emphasis on community based management of chronic disease and direct hospital admission for patients with chest pain, the likelihood of there being no direct contact between primary and secondary care in emergencies increases. Can we facilitate better sharing of medical information in such circumstances, perhaps with patient held records?

One respondent wondered if Peter's primary care physician had failed (although primary prevention of aortic aneurysm is not a realistic option⁵). Others thought Peter's left ventricular hypertrophy could be the result of suboptimal antihypertensive treatment. They discussed the poor sensitivity of electrocardiography in diagnosing left ventricular hypertrophy compared with echocardiography, which guidelines recommend should be confined to the confirmation of electrocardiographic diagnoses.⁶

Another respondent thought that “a healthier life-style is mandatory,” and this included stopping smoking. Given that Peter is probably aware of the risks, strategies such as counselling, nicotine replacement, or bupropion may help him quit smoking.⁷ Parsonage discussed the sensitivity and negative predictive values of the tests described. Other correspondents used or cited³ a similar evidence based approach, but most did not. Perhaps we should reflect it might be as difficult for our patients to adopt evidence based lifestyles as it is for us to practise evidence based medicine.